From the Guidelines
Liver biopsy contraindications include absolute and relative factors, with absolute contraindications being uncooperative patients, severe coagulopathy with an INR >1.5 or platelet count <50,000/μL, and absence of a safe access route, while relative contraindications include ascites, morbid obesity, and extrahepatic biliary obstruction, as supported by guidelines from the British Society of Gastroenterology, the Royal College of Radiologists, and the Royal College of Pathology 1.
Absolute Contraindications
- Uncooperative patients who cannot maintain the required position or follow breathing instructions, increasing the risk of procedural complications
- Severe coagulopathy with an INR >1.5 or platelet count <50,000/μL, significantly elevating bleeding risk, as recommended by guidelines that suggest a transvenous approach if the INR is >1.4 for non-lesional biopsies 1
- Absence of a safe access route to the target lesion due to intervening structures like bowel or lung
Relative Contraindications
- Ascites, which can make it difficult to access the liver and may increase the risk of bile leakage
- Morbid obesity, which can complicate needle placement and increase procedural difficulty
- Extrahepatic biliary obstruction, which raises the risk of bile peritonitis following the procedure, with studies suggesting that liver biopsy should be done for biliary obstruction only when there is doubt about the diagnosis and the benefit to the patient outweighs the risk 1
The decision to proceed with liver biopsy despite relative contraindications should involve careful risk-benefit assessment, consideration of alternative diagnostic methods, and implementation of risk-reduction strategies such as using ultrasound guidance, transjugular approach, or correction of coagulation abnormalities when possible, as recommended by guidelines that emphasize the importance of a rational, evidence-based approach to peri-biopsy management 1.